biofeedback

Sleep Architecture and Wellness

Paul G. Swingle
Ph.D., F.C.P.A., R.Psych.

I
t seems as though every few months I am discovering that what we were taught
in medical and graduate school, when I was trained, is simply wrong. That cer-
tainly seems to be true with regard to conditions such as traumatic brain injury
and the effects of poor sleep architecture. In the present article I’m going to be
discussing some of the effects of insomnia on wellness. In this article I will not
be discussing the effects of sleep apnea, a condition that likewise can also cause
very serious compromises in one’s well-being.

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R
estorative sleep is not simply a func-
tion of how long you spend in bed
or even how many hours of bedtime
you are actually asleep. Restora-
tive sleep refers to sleep architecture; that
is, how much time you spend in each one
of the critical phases of sleep. We also have
learned that although sleeping too little can
be a problem, sleeping too much can also be
a very serious problem, particularly for the
aged.
Insomnia appears to be a prevalent con-
dition with between 20 to 25% of adults
having one or more of the symptoms. The
prevalence appears to be higher in women
(whereas apnea appears to be higher in
men), and the condition appears to be a life-
long disorder if not treated appropriately.
Curiously, insomnia is an under-recognized
and under-treated condition, presumably
because patients may not mention the
symptoms and physicians often do not ask
about sleep quality.
Insomnia is associated with decreased
functioning in many aspects of everyday
life. The condition is associated with more
accidents and falls. It is also related to great-
er incidence of poor work performance and
a high level of risk of days out of role. Days
out of role refers to an individual’s inability
to carry out day-to-day activities including
family care, work and social obligations.
In fact, 10% of accidents and almost 30%
of days out of role have been attributed to
insomnia. And it is interesting that by con-
trast sleep apnea is only associated with
about 1% of these conditions. Insomnia is
also related to elevated comorbid condi-
tions including higher risk for depression,
hypertension, obesity, diabetes, addictions,
chronic pain, urinary complications, gastro-
intestinal conditions, breathing problems
and cardiovascular disorders. As one might
expect, individuals with chronic insomnia
have higher healthcare utilization and in-
creased mortality from all causes.
What we were taught in medical and
graduate school when I was trained was
that insomnia was a symptom of some oth-
er disorder. If you are depressed you have
problems sleeping. If you have general anxi-
ety disorder (GAD), that condition results in
your having problems both falling asleep,
Dr Paul Swingle
remaining asleep and being able to fall back
to sleep upon awakening. If you had chronic
pain, the pain interfered with your sleep. If
you had gastrointestinal problems, the ur-
gencies would awaken you and disrupt not
only the quality of your sleep but your abil-
ity to regain sleep once awakened.
It appears as though this is simply wrong.
Insomnia is not a symptom of the disorder
but it is a cardinal disorder that results in the
symptoms and conditions outlined above.
If your sleep is disrupted, you become de-
pressed or anxious or develop physical con-
ditions such as gastrointestinal problems,
urinary urgencies, pain conditions such as fi-
bromyalgia, chronic fatigue conditions, and
the like.
In short, insomnia should not be consid-
ered a symptom but a disorder in its own
right. It appears that insomnia is a dysfunc-
tion of the switching mechanism between
sleep and wakefulness. The system should
function stably and switch rapidly between
the two states of sleep and wakefulness.
Chronic insomnia represents pathology of
the switching mechanism in which wakeful-
ness intrudes into sleep and sleep intrudes
into wakefulness. Insomnia is a state of hy-
perarousal in which the wakefulness pro-
moting functions in the brain do not deac-
tivate to facilitate transition to the sleep
state. Clients with this dysfunction report
fatigue and tiredness during the day but hy-
perarousal and alertness when they are try-
ing to acquire sleep.
This changing view of insomnia has huge
implications for treatment. Inquiring about
a client’s sleep state should be the first thing
that healthcare providers do when they
talk to a client about their presenting com-
plaints. Hence one might treat sleep to take
care of depression or at least treat sleep
problems simultaneously with any treat-
ments for depressed mood state.
None of this should come as any surprise
if we consider the function of two of the
most important phases of sleep. Deep wave
sleep is a time when the body repairs itself
and builds up energy. We can think of deep
wave sleep as the time when the physical
body is refurbished, the immune system is
strengthened, muscle tissues are repaired,
growth and development is facilitated and
Neuropsychotherapist.com 3
 Sleep Architecture and Wellness
health is maintained. Many sleep experts
have commented that the most damaging
effects of sleep deprivation result from in-
adequate deep wave sleep. In total we only
need about one hour of deep wave sleep
per night. It tends to take a while to get into
deep wave sleep so individuals who are eas-
ily aroused may have difficulty achieving ad-
equate amounts of deep wave sleep.
Whereas deep wave sleep restores the
body, REM sleep restores the mind and cog-
nitive efficiency. I like to think of REM sleep
as the body’s psychotherapy and cognitive
filing mechanism. Inadequate REM sleep is
associated with poor retention of informa-
tion learned during the day. But perhaps
even more importantly, as data we are col-
lecting at the Swingle Clinic suggests, inad-
equate REM sleep is found with clients who
have not adequately dealt with the psycho-
logical sequellae of emotional trauma. In
other words, their native psychotherapeu-
tic system is not working properly. We need
about twice as much REM sleep as deep
wave sleep, about two hours per night.
So when we are looking at sleep architec-
ture, the most important phases of sleep are
deep wave sleep in which we require about
one hour per night and REM sleep in which
we require about two hours per night. It
may well be that if we have good function-
ing deep wave and REM sleep that we only
require a few more hours of the lighter sleep
phases. And interestingly, many of the sen-
ior executives we have in our optimal perfor-
Figure 1:
Five locations included
in the ClinicalQ
brainwave assessment
4 Neuropsychotherapist.com
mance program (Precision Neurometrics) at
the Swingle Clinic sleep about six hours per
night but have consistent, adequate, and
well-placed REM and deep wave compo-
nents.
The Swingle Clinic has introduced a sleep
monitoring assessment program in which
clients take a sleep monitor home and ob-
tain a four-night record of sleep. The monitor
is a wireless EEG recording device that gives
continuous EEG recordings from the fron-
tal cortex over the entire night. We obtain a
four-night record to be sure that the sleep
disturbances that we observe are not simply
transitory but are reliable across a multiple-
night period. The data from our monitor-
ing devices correlates well (about .74) with
polysomnograph technicians’ tabulations
of full head EEG sleep recordings, which is
about as well as the technicians correlated
between their own ratings (.76) on the full
EEG recordings. Further, the sleep assess-
ments usually done in hospitals are only for
one night and take place in a strange (hos-
pital) environment so validity of these snap-
shot assessments may be questionable.
In addition to the sleep assessment, cli-
ents at the Swingle Clinic always have a
ClinicalQ assessment. This is an EEG record-
ing of brainwave activity over 5 critical brain
areas, as shown in Figure 1.
One brainwave measure that is remarka-
bly accurate is the one that identifies a sleep
quality problem (see Table One).
The brainwave data that identifies a

sleep problem are those in the boxed ar-
eas in table one to the right. The area of the
brain where these measures are obtained
is at location O1, the occipital region of the
brain as shown in Figure 1. This is an area of
the brain associated with stress tolerance,
sleep, predisposition to anxiety conditions,
racing thoughts, and vulnerability to addic-
tion. The ratio (1.21) shown in the first box
(table one) is the ratio of slow brainwave am-
plitude (brainwaves between 3 and 7 cycles
per second – Hz) to the amplitude of faster
frequency brainwaves (16 – 25 Hz) when the
client had her eyes open. Referred to as the
“Theta/Beta” ratio, we want to see this ra-
tio between about 1.8 and 2.2. Lower values
are associated with the vulnerabilities men-
tioned above. The second boxed measure is
the Theta/Beta ratio (0.56) when the client
had her eyes closed. As the reader will note,
this value is also considerably below the de-
sired range of 1.8 to 2.2. However, also note
that this number is quite a bit lower than the
already low value obtained with eyes open.
This is the reliable sleep quality marker re-
ferred to above. When the eyes closed ratio
is considerably below the eyes open value,
the clinician can be quite confident that the
client will admit to poor sleep quality.
Although this marker is extraordinarily
reliable, it does not identify the exact nature
of the sleep disturbance. Clinically, we can
often significantly improve a client’s sleep
by improving the Theta/Beta ratios at loca-
tion O1. Some clients respond very well to
brainwave treatments that improve these
ratios but others’ improvement is more lim-
ited. It is for these clients that the four-day
sleep assessment is so valuable because it
not only verifies that the client has a sleep
problem but also tells us precisely what the
problems are with the client’s sleep archi-
tecture.
The Swingle Clinic is developing a data
base of EEG data to identify more precisely
the brainwave functioning anomalies that
are directly related to specific problems with
sleep architecture. This provides greater
precision with treatment than that provided
by the ubiquitous sleep quality marker of
the disparity between the Theta/Beta ratios
eyes open versus eyes closed at location O1
Dr Paul Swingle
TABLE ONE
SUMMARY OF BRAINWAVE DATA FOR CLIENT WITH
SELF-REPORTED SEVERE SLEEP DISTURBANCE.
Let’s look at a case.
As shown in Figure 2 (page 6), this client
has severely limited REM sleep; on this par-
ticular night she only had 19 minutes. Deep
wave sleep looks adequate but she has
markedly excessive wake time. The other
three nights’ recordings showed a similar
pattern, so we are confident that the sleep
disorder is inadequate REM whereas the
deep sleep is fine.
Now if we return to the ClinicalQ brain-
wave assessment summary above, you will
notice that the two areas enclosed in the
hexagons show minus values. These are
markers for exposure to emotional trauma.
This is based on research showing that the
Alpha response in the brain can be blunted
by exposure to intense emotionally nega-
tive experience. The Alpha response refers
to the increase in the strength or amplitude
of Alpha brainwaves when one closes the
eyes. When eyes are closed, the strength
of Alpha brainwaves should increase sub-
stantially because of blocking of the visual
field. In the back of the brain, we expect this
jump in Alpha amplitude to be at least 50%
(that is 50% greater in amplitude compared
with the immediately preceding eyes open
measurement). At the central location, Cz,
we expect this jump in amplitude to be at
least 30%.
Recent research at the Swingle Clinic in-
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 Sleep Architecture and Wellness
Figure 2:
Sleep summary for client with inadequate REM. Red is wake, green is REM, grey is light
sleep and black is deep sleep
dicated that when exposed to a very disturb-
ing picture of a dead body in a concentration
camp, Alpha amplitude was blunted by over
60%, on average, and over 80%, on aver-
age, when compared to the Alpha response
to a positive emotional picture. Earlier work
indicated that for a group of 59 clients with
an Alpha response of less than 10% at both
locations Cz and O1, over 80% admitted
to having been exposed to an emotionally
traumatic event.
The combination of the sleep architec-
ture assessment and the brainwave assess-
ment provides specific data to permit very
precise treatment. It is plausible, for exam-
ple, that this woman is seeking treatment
because of the sequellae of the unresolved
trauma. The trauma may have not been re-
solved because this client had a pre-existing
sleep problem of markedly deficient REM.
REM recall is when the mind restores itself
– the mind’s nightly psychotherapy session.
However, why is she REM deficient? Is it
genetics? Did she have deficient REM sleep
prior to the traumatic event? Or did she have
a predisposition to deficient REM that was
triggered by the traumatic event? Or fol-
6 Neuropsychotherapist.com
lowing the logic of a diathesis stress model,
did she have deficient slow frequency am-
plitude in the occipital region of the brain
that made her stress tolerance poor, which
in turn made her more reactive to the severe
emotional stressor, which in turn triggered
the predisposition to poor REM, which in
turn prevented adequate processing of the
trauma? Contemporary approaches to neu-
rologically-based therapies largely ignore
these, albeit fascinating, complexities and
focus instead on the extant condition.
The cardinal, immediate, therapeutic
goal with this client is to restore adequate
REM sleep. We have found that one Clini-
calQ marker associated with deficient REM
in some clients is deficient Alpha amplitude
in the frontal regions of the brain. The defi-
cient Alpha amplitude is shown in Table One
in the numbers surrounded by the octagon.
The Alpha amplitude should be at least 30%
greater than that shown in the table. This
is a pattern we find with many clients with
trauma markers and it can be conceptual-
ized as hypervigilance. That is, the frontal
regions of the brain cannot rest properly
and are always on alert. So, one of the el-
 Dr Paul Swingle

ements of the neurotherapeutic treatment is to increase the amplitude of Alpha at locations F3 and F4.
The second neurotherapeutic element would be to increase the Theta/Beta ratio at location O1 to facilitate
mental quieting.
But what about the trauma? Clinically, we find that when we increase the Alpha response at locations O1
and Cz, clients usually have an emotional reaction. They often report dreaming more about the event and
frequently report having strange emotions for a short period of time following the Alpha “release.”
We can also focus on the trauma more directly. There are several procedures that can be used to evoke
and experience the trauma, including hypnosis, experiential psychotherapy, eye movement therapies, and
the like, that help with reducing the emotional impact of the recalled experience. And, we find that when
we approach treatment in this manner, the brain responds and the Alpha response is improved, Alpha am-
plitude deficiency frontally recovers and the person reports improved sleep!
None of this should come as any surprise. The brain is very plastic, again as we now know, and will nor-
malize when we provide the conditions that facilitate change. Although these conditions can be very com-
plex, as noted above, neurotherapy is the most direct method for restoring normative functioning. Some-
times we add adjunctive therapies, as outlined above, to facilitate the processing of emotionality to make
the neurotherapy more efficient. While neurofeedback, brainwave biofeedback, is the initial treatment of
choice, in severe or resistant conditions more forceful braindriving procedures are more efficient. Brain-
wave biofeedback, in the above case, would generally begin with increasing the slow frequency (Theta) am-
plitude in the back of the brain. To do this, an electrode would be attached at location O1. With eyes closed,
the client is asked to focus on the tone that she will occasionally hear and see if she can allow the tone to
be present more frequently. The tone, she is told, indicates that the brain is doing what we want it to do -
namely become more efficient at helping her tolerate stress and sleep better. The client is also reminded
that as the brain quiets, she may experience some emotional reactions and to just “let them happen.”
In the majority of cases, this simple process gets the brain back on-line, so to speak, and after 20 sessions
or so, sleep improvement stabilizes. In more resistant situations, we move to the more forceful treatments
including braindriving and one of the adjunctive therapies described above. For braindriving, the electrodes
are placed in the same positions as for regular biofeedback, but in this case, sounds and lights are presented
when the brain is either moving toward more efficient functioning or when it is being resistant to moving,
to nudge the brain into the more functionally efficient state. After braindriving, regular biofeedback proce-
dures are then usually implemented to stabilize the changes.
As always, ask yourself “Who is working on my brain?” Be absolutely certain that the person treating you
is licensed by the province/state to practice a health profession such as medicine or psychology. The prac-
titioner should also be certified to practice neurotherapy. You should also be absolutely certain that they
practice neurotherapy and not some franchised “one-size-fits-all” scheme.

Remember, it’s YOUR BRAIN!

Dr Paul G. Swingle
Dr. Swingle is a clinical psychoneurophysiologist in private practice in
Vancouver. He was Professor of Psychology at the University of Ot-
tawa from 1972 to 1997 prior to moving to Vancouver. He was Lecturer
in Psychiatry at Harvard Medical School from 1991 to 1998 and during
the same time period was Associate Attending Psychologist at McLean
Hospital (Boston) where he also was Head of the Clinical Psychophysiol-
ogy Service. Professor Swingle was Clinical Supervisor at the University
of Ottawa from 1987 to 1997 and was Chairman of the Faculty of Child
Psychology from 1972 to 1977. Dr. Swingle is a Registered Psychologist
in British Columbia and is Board Certified in Biofeedback and Neuro-
therapy.

For more information about neurotherapy see Dr. Swingle’s web-site at

www.swingleandassociates.com.

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